Universal Healthcare Provider Network, a division of Universal Care

Universal House, 15 Tambach Road, Sunninghill Park, Sandton 2191

PO Box 1411, Rivonia 2128
Tel: 0860 111 900 / +27 11 208 1100 / Fax: 0862 957 305 / www.universal.co.za

PATIENT CONSENT FORM (HIV)

TREATING DOCTOR’S DETAILS
Doctor Name: Practice No.:

Telephone no.: Fax no.:

Cell no.: E-mail address:

PATIENT CONSENT FOR THE RELEASE OF MEDICAL INFORMATION
MEMBER’S DETAILS
Surname: Initials: ID/Passport
no:

Membership No:

Medical Scheme/ Health Plan: Occupational Health and Wellness Health Plan:
AECI Medical Scheme Value Option Massmart Network Option WorkerPlan truCARE Option

CompCare Wellness Massmart Essential Option WorkerPlan truWELLNESS Option

CompCare Wellness NetworX Option Old Mutual Staff Fund Network Option Witbank Coalfields Medical Aid Scheme Ntsika Option

CompCare Wellness NetworX Efficiency Discount option Old Mutual Staff Fund Network SELECT Option
Transmed Medical Scheme State Plus Network
Tiger Brands Medical Scheme Mzansi Option
Option

PATIENT’S DETAILS
ID/Passport
Surname: no:

First Name: Age: Dependant Code:

Physical address: Postal address:

Postal code: Postal code:

Telephone no.: Fax no.:

PATIENT’S CONSENT
I hereby give consent to:
• Allow the Universal Care HIV counsellors to obtain clinical information and records relating to me or my dependants’ (child or legal beneficiary) health, treatment and any other aspects
of medical care provided,
• Allow any health care worker responsible for the management of my treatment to share my clinical information with the Universal Care HIV counsellors or Case Managers.

I confirm/understand that:
• Counselling/education on HIV/AIDS has been offered to me in a language that I understand,
• I am able to make an informed decision to voluntarily join the Universal Care HIV programme,
• A Universal Care counsellor will be available for me to consult should I require it,
• The purpose of performing diagnostic pathology tests is to establish my HIV status, to monitor, clinically treat and manage my HIV and that I understand the implications of knowing my
HIV status,
• Ongoing testing and monitoring of my condition is required as part of the programme and that the treatment protocol may change based on the outcome of any test,
• Should I not comply with the programme protocols or prescribed treatment that the Medical Scheme, at its sole discretion, may elect to exercise its right to limit my benefits to the
statutory prescribed minimum benefits,
• I voluntarily consent to the drawing of blood samples and to the testing of such blood samples in order to establish my HIV status, as well as the subsequent drawing and testing of
blood samples to monitor and treat my HIV condition,
• Universal Care is the administrator of the programme and that my selected GP is responsible for the management of my condition, including the prescription of medication. Therefore
Universal Care or the Medical Scheme will not be liable for claims by me or my dependants arising from my participation in the programme.
• My clinical information regarding my HIV status will not be shared with my employer without my written consent,
• I may voluntarily withdraw from the programme, but understand the implication thereof,
• That all the information I have provided for the completion of this form is accurate and complete,
• I have been given a copy of this document.
This consent is in respect of any matter on file with any physician or health care provider. The information obtained will not be divulged to any other individual, institution or organization, except
to such persons who are required to receive such information in the ordinary course of their employment at Universal Care or the Medical Scheme’s administrator or the Medical Scheme itself.
Universal Care and its employees shall not be held liable should my personal information or HIV status be unauthorised and unintentionally disclosed to a third party or revealed to a third
party through coding of accounts using ICD10 codes.

D D M M Y Y Y Y

SIGNED AT: PATIENT SIGNATURE:

WITNESS FULL NAME: WITNESS SIGNATURE: